Registration Form - Active Aldershot

A Short Tagline or Description

2019 Summer Camp Registration Form

Full Name

Name*

Address

City

Province

Postal Code

Personal

Home Phone*

Age

Date of Birth (dd/mm/yy)

Email Address*

Mother’s Info

Mother's Name

Use as primary contact

Mother's Phone

Mother's Business

Mother's Cell

Father’s Info

Father's Name

Use as primary contact

Father's Phone

Father's Business

Father's Cell

Emergency Contact

Emergency Contact (if different from above)

Relationship to student

Emergency's Phone

Emergency's Business

Emergency's Cell

Health Information

Family Doctor

Family Doctor Phone

Health Card No

Health, Learning or Behavior ConcernsYesNo

If "Yes", please give details

Does this participant carry and know how to administer his/her medication?

Other Informtion (e.g. Braces, Contact lenses etc)